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When colostomy is the only option
Colostomy is a surgical operation in which a piece of the colon is diverted to an artificial opening in the abdominal wall (stomach) so as to correct an obstruction or damaged part of the colon. Photo by Steven Otage.
What you need to know:
An imperforate anus is a defect that is present from birth. The opening to the anus is missing or blocked and therefore, surgery to correct the defect should be done. If the rectum connects with other organs, these organs will also need to be repaired. A temporary colostomy is often needed.
Hawa Babirye Mirembe is a mother of five. All the older children were born normal but the fifth delivery came with complications of cord prolapse (a condition where the umbilical cord comes out of the uterus with or before presenting part of the foetus). She had a C-section birth at Nsambya Hospital on June 29, 2015 but the baby had a narrow anal opening.
“Right at birth, the doctors detected there was a mass blocking in his anal area but they thought it would widen and become normal as the baby grew. At two months, the baby would cry and use a lot of pressure to pass out stool. It was very painful for him. I was advised by a nurse to use an enema administration, a technique used to stimulate stool evacuation. The liquid treatment was expensive for me because a bottle goes for Shs20,000 but it was the only solution for my baby.
Mirembe says she used the treatment until the baby was four months but then it had stopped being effective. He had developed a hard block in the stomach and his feeding reduced. He was weak, could not feed well, cried all the time and could not pass out stool.
“I was advised to see a peadiatrian at Surgeon’s Plaza in Kamwokya who recommended an immediate surgery at Mulago Hospital,” she says.
Free surgery
The surgery, the doctor said, was first to help the baby pass out stool but since the theatre was closed, we were referred to Naguru Hospital and the surgery was free.
“He now has an opening on his stomach where stool passes. I ensure the area is clean and dry to avoid any infections like the doctors told me. His next operation to correct the anal defect is just a few days away from now and later, he will undergo another one to reverse or put the intestine back to its normal position. I think he will be fine thereafter,” Mirembe narrates.
Dr John Ssekabira, a consultant Peadiatric Surgeon at Mulago Hospital, says the defect where the baby has an improperly developed anus happens while the baby is still growing but the cause is still unknown. The condition is a serious one that requires immediate treatment and the doctors usually diagnose it shortly after birth. Such babies need surgery immediately to correct the defect.
“More than 30 per cent of the children at the peadiatric ward have the congenital problem of anorectal malformation where the anal area is blocked by a mass or is completely not there. Such children need the colostomy surgery as soon as the doctor finds out,” says Dr Ssekabira.
Signs and symptoms
The signs of an imperforate anus are usually obvious soon after birth according to Dr Ssekabira. They may include: no anal opening, anal opening in the wrong place like near the vagina or urinary bladder, no stool in the first 24 to 48 hours of life, stool passing through a wrong place like urethra, vagina or the base of the penis, a swollen abdomen or fistula between your baby’s rectum and the reproductive system or urinary tract.
Some babies born with an imperforate anal area have associated problems with the kidney, heart, spinal cord, esophageal defects, urinary tract defects, bone defects with the arms and legs so the doctor should check out for these conditions.
Diagnosis
A doctor can usually diagnose imperforate anus by performing a physical exam after birth. X-rays of the abdomen and abdominal ultrasound can confirm the problem and reveal the extent of the abnormalities.
Other conditions
There are other conditions that may also require that a person goes through the same surgical procedures according to Dr Ssekabira. They include acquired conditions from infections such as typhoid, warts or cancers that affect the bowel or pelvis.
The procedures may still be applicable after incidences of accidents and sexual assault that may cause damaging or obstruction of the rectum. Some people may have problems with the nerves to the intestines so they cannot pass stool normally.
Treatment
An imperforate anus is treatable according to Dr Ssekabira although due to poverty and a poor health seeking culture, people with such children do not seek treatment.
The condition requires multiple surgical procedures and first is a temporary colostomy to allow the baby time to grow before surgery.
For a colostomy, the surgeon creates an opening on the abdomen. They attach the lower part of the intestines to one opening and the upper part of the intestines to the other. A pouch is attached to the outside of the body catches waste products.
“The pouches (Colostomy bags) are very costly and are not provided by the government and the mothers cannot afford them so they improvise with clean pieces of cloth that they tie around the waist area to hold the stool,” says Dr Ssekabira.
The type of corrective surgery needed will depend on the specifics of the defect, such as how far your baby’s rectum descends, how it affects the nearby muscles, and whether there are fistulas involved.
In the surgery, the surgeon closes any fistulas so that the rectum no longer attaches to the urethra or vagina. He then creates an anus in the normal positioning.
Lynn Tendo, a first time mother whose child had an anal area near the vagina, says, “It may be necessary to stretch the anus periodically. The doctor will instruct you on how to perform anal dilations to prevent the anus from narrowing after it has been created in the second surgery. You may need to repeat this periodically for a few months. Your doctor can teach you how to perform this at home.”
The last surgery is a pull-through operation where the surgeon pulls the rectum down and connects it to the new anus.
The child hereafter should be able to use their anal area well but toilet training may take a bit longer especially for some children that are operated on when they are older because their muscles are usually weak. Sometimes they may have no voluntary control of the stool so it may be difficult to lead a normal life there after. It is therefore advisable to take the child for surgery as soon as possible. A diet high in fiber and regular follow-up care throughout childhood are helpful.
Background
Anorectal malformations include a wide spectrum of defects in the development of the lowest portion of the intestinal and urogenital tracts. Many children with these malformations are said to have an imperforate anus because they have no opening where the anus should be. Although the term may accurately describe a child’s outward appearance, it often belies the true complexity of the malformation beneath. When a malformation of the anus is present, the muscles and nerves associated with the anus often have a similar degree of malformation. The spine and urogenital tract may also be involved.
The position and nature of these malformations made repair difficult for early surgeons. The affected organs are located deep in the pelvis and are not well visualized through abdominal incisions. Traditional surgical dictum did not allow for division of the posterior midline because this division of the muscle was believed, somewhat erroneously, to cause incontinence in the child. Therefore, surgeons approached these malformations using a combined abdominal, sacral, and perineal approach, with limited visibility. Such approaches have put continence, and surrounding genitourinary structures, at greater risk than simply cutting sphincter muscles because of the difficulty of adequately visualizing the malformation through limited incisions. This principle was central to the development of the surgical techniques currently used to repair these malformations.
In 1982, Peña et al reported the results of the use of a posterior sagittal surgical repair approach.[1] Peña et al used the traditional approach with a sacral incision and made the incisions progressively larger in an attempt to adequately visualize the anatomy. Eventually, the entire posterior sagittal plane was opened, affording a full view of the complete malformation. This technique, referred to as posterior sagittal anorectoplasty (PSARP) or posterior sagittal anorectovaginourethroplasty (PSARVUP), has led to a more complete understanding of the anatomy of these children and of what is required to repair the malformations with optimal results.
After reconstructive surgery for the malformation, many children still experience effects in the form of urinary or fecal incontinence. Despite optimal surgical management, no adequate repair for poorly developed muscles or nerves has been developed. Bowel-management regimens can provide an excellent quality of life for these children when primary continence is not achievable.
